Grabovac I, Mustajbegović J.

Healthy occupational culture for a worker-friendly workplace

Arh Hig Rada Toksikol 2015;66:1-8 1
Mini-review DOI: 10.1515/aiht-2015-66-2558

Healthy occupational culture for a worker-friendly

workplace

Igor Grabovac1 and Jadranka Mustajbegović2

Institute for Occupational Medicine, University Clinic for Internal Medicine II, Medical University of Vienna, Austria1,
Department of Environmental Health and Occupational Medicine, School of Public Health “Andrija Štampar”,
School of Medicine, University of Zagreb, Croatia2

[Received in July 2014; CrossChecked in July 2014; Accepted in January 2015]

Work has numerous health and wellbeing benefits, but it also involves physical hazards and psychological exertion. Today
the scale has tipped toward psychosocial factors. Workers’ mental health affects their intellectual, emotional, and social
growth, as well as work ability, productivity, and ultimately organisational productivity and competitiveness on the market.
Even though companies may have an internal hierarchy that lowers stress at work, there are other formal and informal
social processes that can affect (positively or negatively) the cohesion within the work unit. Safety culture of an organisation
is a product of individual and group values, opinions, competences, and behavioural patterns that determine how
occupational health and safety are implemented. Organisations that nurture positive safety culture understand the importance
of health and safety and believe in prevention rather than dealing with consequences. Jobs that are stable, autonomous,
and reasonably physically and psychologically demanding are far more likely to lower work-related stress and boost
worker satisfaction. In fact, employee empowerment is one of the best ways to achieve good psychosocial health at the
workplace.

KEY WORDS: healthy organisations; mental health; organisational culture; stress; workers wellbeing

Approximately 58 % of the world population, that is, 4
billion people, spend one third of their adult lives at the
workplace. Around 120 million workplace accidents and
2.3 million deaths are reported every year. About 318,000
deaths are related to injuries at work and almost 2 million
to exposure to workplace hazards and unsafe working
conditions (1, 2). In 2013, Croatia saw 13,796 work-related
injuries, of which 1,700 were severe and 17 fatal. In
addition, 209 new cases of professional illness were
reported (3).
Mental health at the workplace
One out of four people will develop one or more mental
or behavioural difficulties during their lifetime. Psychiatric
conditions account for 7.4 % of the total disability-adjusted
life years (DALYs), with the highest loss in the population
between 10 and 29 years. Estimates predict that their share
will reach 15 % by the year 2020 (4). Four out of ten leading
reasons for disability and premature death worldwide are
psychiatric conditions (4, 5). In industrialised countries and
the EU mental illnesses are responsible for 4 % and 1 % of
deaths at the workplace, respectively (2). Furthermore,
mental health issues are among the leading causes of
absenteeism and early retirement everywhere in Europe.
These issues are a great and long-lasting economic burden
for employing organisations. A UK study (6) showed that
mental health illnesses cost employers almost 26 billion
pounds a year: 8.4 billion for sick leave payments, 15.1
billion for production losses, and 2.4 billion for replacing
the employees who left. In Croatia, mental health illnesses
are the second leading cause of disability, neurosis, stress,
and somatoform disorder in particular (7).
Due to changes in job tasks and work organisation a
relatively low number of jobs are still physically demanding,
as the demands have shifted toward mental and emotional,
which makes psychosocial risk factors at the workplace
even more prominent. Although the strength of evidence
about the relationship between psychosocial risk factors at
the workplace varies, almost all research confirms that
psychosocial health of the employees correlates with
occupation in all mortality cases, coronary heart diseases,
psychiatric illnesses (especially depression), and chronic
bronchitis (8).

Correspondence to: Prof Jadranka Mustajbegović, MD, PhD, Organisational culture of health and safety at work
Department of Environmental Health and Occupational Medicine,
School of Public Health Andrija Štampar, Rockefellerova 4, 10000 Ravasi and Schultz (9) define organisational culture as
Zagreb, Croatia, E-mail: jmustajb@snz.hr combined mental assumptions that determine the way of
2 Grabovac I, Mustajbegović J. Healthy occupational culture for a worker-friendly workplace
working within organisations by defining what behavioural
patterns are acceptable in different situations.
Organisational culture involves a number of psychosocial
factors and mostly relies on informal aspects of work and
its organisation. Simply put, it is what people in an
organisation find appropriate or not. A colloquial
explanation would be: “it is the way we do things here”
(10).
Organisations should encourage a “healthy”
organisational culture in order to increase productivity,
economic growth, and management efficacy, and to
discourage behavioural patterns that lower productivity and
increase employee turnover (Table 1). Organisations with
an adaptive organisational culture have better economic
performance than those without it (11).
While the awareness of health risks at the workplace is
growing among the worker population, in the managerial
structures the lack of awareness is a serious obstacle to
developing necessary measures to protect health at work.
Additional obstacles may be the fear of high costs, shortage
of funds, work fragmentation, and new work forms such as
small businesses, distance working, self-employment, and
the increasing gap between health care and economy sectors
(1).
From the health sector ’s point of view, poor
organisational health and safety culture often leads to stress
and adverse health effects in employees. Although none of
the EU member states has a specific legislation for stress
at the workplace, all legal frameworks do refer to
psychosocial factors as those that can cause or aggravate
stress at the workplace. According to the European Agency
for Safety and Health at Work (EU-OSHA) (12), 80 % of
the managers in the EU consider stress to be a problem in
their organisations, but only 30  % say that they have
implemented some sort of stress management programme
or a programme that deals with psychosocial issues at the
workplace. Half the respondents claim that psychosocial
issues at the workplace are harder to manage than the more
“traditional” hazards.
According to the same report by EU-OSHA (12),
Croatia is one of the least likely countries to take preventive
measures against psychosocial issues; stress management
programmes are implemented in only 25  % of the
respondent organisations, while only 23 % use psychologist
services. In Belgium, Denmark, Germany, the Netherlands,
Table 1 Early signs of poor organisational culture of health and safety at work
Individual
Unusual behaviour
Poor work results
Mood swings and changes
Problems with co-workers
Increase in absenteeism due to illness
Cannot keep one job for long
Arh Hig Rada Toksikol 2015;66:1-8
and Sweden, legislation goes a step further than the EU
legislation and stipulates that employers should actively
work to reduce these risk factors. In the United Kingdom
stress management programmes are more often
recommended than obligatory, although health and safety
laws do express concern about stress (13-15).
Formal and informal organisational influences
The Whitehall II Study (16, 17) showed that civil
servants at the bottom of the hierarchy were six times more
absent from work than others, which is related to a
perception of lower control over job tasks, low social
support, and higher incidence of mental health issues.
Authors such as Carayon, Hoonakker, and Smith (18, 19)
believe that in the centre of organisational design and
management (ODAM) is the relationship between
management philosophy, satisfaction, and productivity of
employees; employees accept managerial decisions more
easily if they too hold them necessary, if the decisions have
been clearly outlined, and if the lines of responsibility are
clearly set. All this lowers stress that would otherwise arise
from conflicting roles. Technological innovations and
education that help with job tasks also tend to actively
involve employees in problem solving, decision making,
and encourage them to speak their minds freely (20,21).
Research is now shifting focus on issues related to
organisational structure and the relationships between
superiors and subordinates. Organisational structures that
are based on a clear hierarchy are inexpensive, efficient,
and easily maintained; this is why they are most common
in the world. However, parallel to this formal structure,
there is an informal social interaction between employees
and the employers. As early as the 1920s, the Hawthorne
studies (22) have shown that people do not work for
financial gain alone, but also because they want to belong
to a collective, and produce something meaningful. In other
words, they are equally influenced by intrinsic (psychological
and social benefits) and extrinsic (payment and financial
benefits) work factors.
Informal social processes greatly affect the efficacy of
work organisations and work in teams, even where the
formal organisational structure is good. They can affect the
cohesion within and between work units and the relationship
between workers and the organisation and can undermine
Organisation
Growing backlog, low production, more overtime hours
Lower work quality (more production errors)
Less clients and inadequate service
Increase in sick leave
Inefficient cooperation between employees and departments
Higher employee turnover
Grabovac I, Mustajbegović J. Healthy occupational culture for a worker-friendly workplace
Arh Hig Rada Toksikol 2015;66:1-8
the formal structure and decrease productivity. It is
important to know that informal processes have the same,
if not even greater power to change beliefs, attitudes, and
behaviour of workers and ultimately lead to the establishment
of social norms within the work unit. Usually these are
mutually set social norms about the quantity of the work
that is to be done and the relationship with the superiors.
Every deviation from these norms leads to an increase in
social pressure and stress, which disrupts productivity.
Therefore it is necessary to match formal and informal
influences so that the employees can actively participate in
improving productivity (23, 24). This can be achieved in
different ways that are all based on active communication
with workers, such as focus groups and work units that are
dedicated to solving a specific problem, then on education
and safe working conditions, which all comes down to
creating a healthy work organisation. Protecting health and
safety at the workplace is much more than just focusing on
formal aspects of prevention of harmful effects that result
from work processes, work tasks, and workplace
environment. At the core of ensuring health and safety at
work are people; therefore all organisations who wish to
invest in and maintain human capital should pay close
attention to behavioural, social, and cultural processes (24).
Healthy work organisation concept: connecting
organisational culture and health
The healthy organisation concept encompasses
managerial and business understanding of health in relation
to organisational culture. It is built on the simple premise
that a happy, content, and calm worker is a healthy and
productive worker. Healthy organisations are those whose
culture, management, working environment, and business
practice create an atmosphere that improves health,
efficiency, and quality of employee’s work (18, 25). A
growing amount of data indicates that the most successful
and competitive companies are those that have the highest
levels of health and safety and the most physically and
mentally healthy and satisfied workers (26). Crimmins and
Halberg (27) define “health culture” as a mixture of attitudes
and beliefs of employees towards health promotion
programmes at the workplace. An optimal social
environment is necessary in order to improve psychosocial
and physical health of the employees. The World Health
Organization (WHO) in its new model of health and safety
protection at the workplace includes the “internal working
environment” (which encompasses both individual physical
health and psychosocial well-being) as well the need for
connections between work organisations, communities, and
the environment that the workplaces are a part of (26). Such
a broad model of understanding health and safety at work
makes it necessary that occupational medicine physicians,
ergonomics and human factors specialists consider the
wider aspects of social policies, economy and the
environment (28-30). Peterson and Wilson (31) suggest that
3
occupational medicine specialists and experts who research
organisational development should focus on developing
interventions that encompass organisational culture through
the perspectives of health of individual workers as well as
the whole organisations.
Increasingly important and driven by globalisation is
the diversity management at the workplace. Many
experiences are common to all minority groups and
encompass stereotyping, discrimination, harassment,
violence, and exclusion from formal an informal exchanges
at the workplace (32). A working environment that is more
receptive to diversity attracts better workers and has lower
employee turnover. Employee turnover may cost up to
150 % of the regular cost of the employee who has left the
position. Therefore, successful organisations regularly
monitor employee turnover and report the findings every
year as a measure of success (33).
The success of entrepreneurship depends on technology,
tolerance, and talent (the “3T”), and developing new
technologies and talent depends on tolerance within an
organisation (34). Research has shown that non-heterosexual
individuals who feel safe enough to come out in the
workplace are more efficient, more motivated, and feel
better about their relationships with co-workers.
Furthermore, hiding one’s sexual orientation at the
workplace reduces productivity up to 30  %, while
organisations that provide their workers with support
groups, mentoring programmes, etc. have 7-16 % higher
scores in questionnaires about satisfaction and productivity
at the workplace in comparison to those that do not (35).
Sense of security is crucial for establishing good
interpersonal relationships at the workplace (36).
Organisations that value employee diversity and allow free
expression of this diversity and those that are culturally
heterogenic have better results than those that are culturally
homogenous, as they encourage creativity and innovation
(35, 36-38).
Work satisfaction and productivity
In 1975, Katzell et al. (39) showed that increasing
worker satisfaction did not necessarily increase productivity.
They saw two obstacles to this: resistance to implementing
change and focusing on just one approach instead of
implementing system-wide changes. Therefore, they
suggested seven principles to increase both workers’
satisfaction and productivity:
1. Critical-Mass Principle: changes in the organisation
need to be sufficiently deep and far reaching in order to
have a lasting effect;
2. Motivation Principle: development of a workforce
that is dedicated to the concept of high productivity through
financial and/or psychological rewards;
3. Shared Benefits Principle: workers need to see that
organisational changes that increase productivity benefit
them as well;
4 Grabovac I, Mustajbegović J. Healthy occupational culture for a worker-friendly workplace
4. Job Design Principle: changes need to be implemented
so that the workers see them and actively participate in their
implementation. The implemented changes have to ensure
optimal working conditions;
5. Pattern of Control Principle: higher autonomy and
self-regulation can be key to increasing work satisfaction;
organisations in which all workers have a certain level of
control are more productive and motivated;
6. Patterns of Compensation Principle: adequately paid
workers generally like their job, are more satisfied, have
lower absenteeism levels and more rarely leave their jobs.
However, pay needs to be connected with the productivity
level;
7. System-Wide Changes Principle: changes need to
include the whole organisation and need to create “new”
work systems) (40).
Newer studies seem to support the idea of happy and
healthy workers as productive workers. Organisations that
promote healthy and safe working conditions ensure
economic growth through the trust that they build within
the community (40, 41). Quick and Quick (42) suggest that
creating a happy, healthy, and productive workforce should
rely on the principles and knowledge of occupational
medicine and public health (42). This in turn calls for
preventive health programmes that seek to develop the
abilities of the worker population and eliminate conditions
that lower this ability. These programmes should also plan
and implement healthy practices following the principles
listed in Table 2.
Proposed procedures in developing a healthy
organisation
This process requires complete cooperation and
consensus between the management and workers. One of
the most important ways to protect workers’ psychosocial
health is to empower the employees and include them in
decision making (43).
According to several authors (29, 36, 43), the seven
steps listed below are the fundamental building blocks for
any healthy organisation:
1. Communication, consultation, and informing
It is necessary to obtain consent and make sure that all
organisational levels are devoted to protecting health of all
employees, regardless of their status or position in hierarchy.
All organisation units need to actively shape, conduct,
supervise, and evaluate adopted programmes. It is
recommended to form a group of workers to supervise and
implement the adopted programmes in cooperation with
outside experts such as union members, psychologists, and
occupational medicine physicians. All the employees need
to be clearly and regularly informed about the implementation
steps and need to be given an active role in implementation.
This will increase the perceived importance of the
programme and their willingness to participate and
Arh Hig Rada Toksikol 2015;66:1-8
implement the agreed changes and policies. Workers can
be informed about the program via internet or monthly
bulletins, regular meetings of working groups, or specific,
task-oriented meetings. The importance of good
communication is paramount.
2. Recognition of needs
Programmes should be clear about what needs to
address, such as promoting healthy attitudes towards health
at work, understanding and preventing stress and health
risk factors, supporting employees with health problems
and including them back into the work environment. It is
also necessary to recognise the strengths and weaknesses
of a specific health promotion programme. This analysis
needs to be done in cooperation with all employees,
regardless of their position in hierarchy. This cannot be
repeated enough times.
Approaches to determining the needs differ and
complement one another (10, 44). They broadly fall into
three categories: academic (or anthropological), analytical
(or psychological), and pragmatic (10). They also differ in
the observed timeline (past, present or future), kind of
information that is derived (quantitative or qualitative),
form/features of the information (descriptive or normative),
and strategies, methods, and instruments used (44).
3. Determining objectives
The objectives should be “measurable” using appropriate
analytical methods; for example, an objective could be to
reduce perceived stress caused by a determined stressor by
10  % within a year or to reduce absenteeism due to
psychosocial health issues by 5  % within 2 years or to
reintegrate or hire a number of individuals who had a longer
period of sick leave or had health issues over the last two
years.
4. Developing specific plans and measures
After determining the objectives and the time frame, it
is necessary to define the means to achieve these objectives.
They usually include informative campaigns that raise
awareness about a certain issue within the organisation,
education and training for employees and employers,
actions aimed at reducing discrimination and violence at
the workplace, methods for removing stressors at the
workplace, policies aimed at helping people who develop
health problems, and discrimination-free employment
strategies.
It is necessary to adjust the strategies used in the
programme to the culture and needs of the community as
well as to different segments of the employee population,
as the success of new or already implemented programmes
depends on it (24).
Grabovac I, Mustajbegović J. Healthy occupational culture for a worker-friendly workplace
Arh Hig Rada Toksikol 2015;66:1-8 5
Table 2 Principles of healthy and productive organisations

Organisations need to hold human resources at least as important as other resources

Importance of human resources
Relationship between worker's
health and wellbeing and
organisational health
Increasing motivation at the
workplace
The need for continuous
monitoring and evaluation
Importance of balancing
personal life and work demands
Relationship between wellbeing
and productivity
(capital, structures, equipment, materials, etc.)
Organisations need to be aware that health and wellbeing of their workers directly
corresponds to the wellbeing of the organisation
Workplaces should motivate workers to perform in an efficient and productive way.
Work tasks need to designed done in such a way that workers look forward to their
time spent at work
There are many different organisational cultures and ways of management that
promotes wellbeing and satisfaction in workers. Organisations need to keep track of
employee attitudes and make timely changes in order to improve their wellbeing and
satisfaction at work
Organisations need to be aware that work influences different aspects of life. Therefore
it is important that organisations create policies and programmes that allow workers to
establish a good balance between work and personal lives
Workers with good emotional wellbeing will be more productive and less likely to
change workplaces. Also workers who are less stressed and more productive are those
who:
- are adequately paid for their work and have a degree of financial security
and whose pay is linked to the quality of their work and the economic
growth of the organisation
- have an active role in decision making and control over their work tasks
- receive realistic demands, harmonised with their capabilities, needs, and
expectations
- are given the conditions to succeed
- are given social support from co-workers and supervisors
- work in conditions that accept diversity

Importance of trust, respect, Organisations need to implement activities and programmes that develop trust,
and decency respect, and righteousness between co-workers, supervisors, and managers

Organisations need appropriate supervision, fair benefits, safe employment, and good
Adequate work hygiene
physical and social working conditions

5. Implementation of the programme
It is crucial to make a clearly written document about
the implementation of the programme, measures to be taken,
and other planned changes within the organisation. This
document should be a joint declaration of employers and
workers as to what is and what is not acceptable, how to
resolve possible disputes or conflicts, and what sort of
disciplinary measures workers can expect. All workers
should be clearly informed and actively participate with
suggestions in the making of such a document. All should
sign it and be responsible for its implementation (45-47).
When one considers the efficiency of the prevention
programme, special care should be taken to determine
programme implementation standards that should be
sensitive to cultural norms, financial and research
possibilities assuring its reimplementation on the basis of
the written documentation.
6. Evaluation
Programme evaluation has to clearly and unequivocally
show whether the agreed objectives have been reached or
not. Evaluation should take place as previously scheduled
during programme implementation. The results should be
clearly communicated to everyone in order to increase the
interest of the workers for the programme and introduce
corrective measures if needed (18, 47, 48).
7. Ensuring sustainability
The only way to ensure the sustainable plans and
programmes for preserving health at the workplace for long
is to include them in the official work policies of the
organisation (48).
Programmes that address several issues at the same
time, that increase physical, mental, and social aspects of
health are cost effective and usually the most appealing to
employers. Such programmes can lower the risk of a variety
of disorders or illnesses and increase the overall health level
of the workers.
The shining examples are the programmes included in
the online databases made available to anyone interested
by the UK Evidence for Policy and Practice Information
and Co-ordinating Centre, who developed the Database of
6 Grabovac I, Mustajbegović J. Healthy occupational culture for a worker-friendly workplace
promoting health effectiveness reviews (DoPHER), the
EU-OSHA’s Case Studies, and the US Center for Disease
Control and Prevention (CDC) Prevention through Design
programme (49-51).
Of course, the implementation of such programmes
needs to be harmonised with national health policies and
the level of health services, as these differ between
developed, developing, and underdeveloped countries. In
order to ensure interest and participation of governmental
and non-governmental agencies, experts in health care,
education, labour, economy, law, and target populations,
these databases need to give information about the costs
and benefits of these programmes.
Finally, for the maximal benefit it is necessary to
maintain effective and sustainable cooperation between
countries and international non-governmental agencies.
CONCLUSION
Organisations that nurture positive health and safety
culture are aware of the importance of safety and preventive
measures.
Healthy organisations not only increase productivity,
but also preserve it in the long run. Not only do they protect
worker’s physical and mental health at work, but also teach
them to apply their knowledge after they leave the
workplace.
With the skyrocketing unemployment rates, employers
and managements in Croatia and other transitional countries
do not seem to prioritise happiness, satisfaction, or health
of their workers, as there are many left to replace them.
The ever increasing health protection costs give
prevention a poor starting position, as its results are not
immediate to see. However, as the Croatian Institute for
Health Protection and Safety at Work has recently joined
the European Network for Workplace Health Promotion
(ENWHP), which is an advisory body to the European
Commission, there is hope that knowledge about the
importance of healthy organisations will spread not only in
Croatia and EU but worldwide.
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8 Grabovac I, Mustajbegović J. Healthy occupational culture for a worker-friendly workplace
Arh Hig Rada Toksikol 2015;66:1-8

Kultura zdravih organizacija – radna mjesta prijatelji radnika

Radni uvjeti, radni okoliš i sam način rada znatno utječu na zdravlje. Danas je relativno malo poslova definirano tjelesnim
zahtjevima, a puno više mentalnima i emocionalnima, pri čemu psihosocijalni rizici postaju značajni. Uz brojne pozitivne
utjecaje rada na zdravlje i blagostanje, mnogi su radnici izloženi i opasnostima, štetnostima te ergonomskim i psihološkim
naprezanjima. Stanje mentalnog zdravlja zaposlenog omogućava razvijanje u emocionalnom, intelektualnom i socijalnom
pogledu te ima odlučujuće učinke na radnu sposobnost, zahvaćajući ne samo način i ishode njegova rada nego i ishode
poslovanja tvrtke ili ustanove, određujući njenu kompetitivnost na tržištu. Unatoč dobroj organiziranosti upravnih tijela
tvrtke, što umanjuje stres na radu, neformalni društveni procesi utječu (pozitivno ili negativno) na koheziju unutar radnih
jedinica i na osjećaj povezanosti radnika i organizacije. Kultura sigurnosti neke organizacije rezultat je individualnih i
grupnih vrijednosti, stavova, kompetencija i oblika ponašanja. To, pak, određuje odlučnost i način vođenja programa za
očuvanje zdravlja i za sigurnost u organizaciji. Značajke organizacija koje imaju pozitivnu kulturu sigurnosti su zajednička
percepcija važnosti sigurnosti te pouzdanost u preventivne mjere. Rad koji omogućuje autonomiju, kontrolu nad svojim
radnim zaduženjima, razumne tjelesne i psihološke zahtjeve te sigurnost od iznenadnih otkaza dovode do većeg zadovoljstva
radnika i smanjuju stres na radnome mjestu. Danas se sve više ističe važnost različitosti na radnome mjestu. Potrebno je
istaknuti kako je upravo osnaživanje zaposlenika jedan od najvažnijih načina očuvanja psihosocijalnog zdravlja.

KLJUČNE RIJEČI: blagostanje radnika; mentalno zdravlje; organizacijska kultura; stres; zdrave organizacije
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